International Journal of Environmental Research and Public Health

Case Report Understanding South Korea’s Response to the COVID-19 Outbreak: A Real-Time Analysis

1, , 1, , 1, , 2 Eunsun Jeong * † , Munire Hagose * † , Hyungul Jung * †, Moran Ki and Antoine Flahault 3

1 Institute of Global Health, University of Geneva, 1211 Geneva, Switzerland 2 Department of Cancer Control and Policy (DCCP), Graduate School of Cancer Science and Policy, National Cancer Centre (NCC), Goyang 10408, Korea; [email protected] 3 Institute of Global Health, Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland; [email protected] * Correspondence: [email protected] (E.J.); [email protected] (M.H.); [email protected] (H.J.) These three authors contributed equally. †


Received: 11 November 2020; Accepted: 16 December 2020; Published: 21 December 2020


Abstract: This case study focuses on the epidemiological situation of the COVID-19 outbreak, its impacts and the measures South Korea undertook during the first wave of the COVID-19 pandemic. Since the first case was confirmed on 20 January 2020, South Korea has been actively experiencing the COVID-19 outbreak. In the early stage of the pandemic, South Korea was one of the most-affected countries because of a large outbreak related to meetings of a religious movement, namely the Shincheonji Church of Jesus, in a city called Daegu and North Gyeongsang province. However, South Korea was held as a model for many other countries as it appeared to slow the spread of the outbreak with distinctive approaches and interventions. First of all, with drastic and early intervention strategies it conducted massive tracing and testing in a combination of case isolation. These measures were underpinned by transparent risk communication, civil society mobilization, improvement of accessibility and affordability of the treatment and test, the consistent public message on the potential benefit of wearing a mask, and innovation. Innovative measures include the mobile case-tracing application, mobile self-quarantine safety protection application, mobile self-diagnosis application, and drive-thru screening centres. Meanwhile, the epidemic has brought enormous impacts on society economically and socially. Given its relationship with China, where the outbreak originated, the economic impact in South Korea was predicted to be intense and it was already observed since February due to a decline in exports. The pandemic and measures undertaken by the government also have resulted in social conflicts and debates, human-right concerns, and political tension. Moreover, it was believed that the outbreak of COVID-19 and the governmental responses towards it has brought a huge impact on the general election in April. Despite of the large outbreak in late February, the Korean government has flattened the COVID-19 curve successfully and the downward trend in the number of new cases remained continuously as of 30 April. The most distinctive feature of South Korea’s responses is that South Korea conducted proactive case finding, contacts tracing, and isolations of cases instead of taking traditional measures of the containment of the epidemic such as boarder closures and lockdowns.

Keywords: South Korea; coronavirus; COVID-19; global health; case study; epidemiology; non-pharmaceutical interventions; health systems

Int. J. Environ. Res. Public Health 2020, 17, 9571; doi:10.3390/ijerph17249571 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020, 17, 9571 2 of 18

1. Introduction A novel coronavirus, namely COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) has emerged in Wuhan, China in December 2019. A few weeks later, the World Health Organization (WHO) announced the outbreak of a new virus. As the epidemic has spread across the world at an unprecedented rate, the WHO declared, on the 31st of January 2020, the 2019 novel coronavirus as a Public Health Emergency of International Concern [1]. Neighbouring countries to China such as Thailand and South Korea were the first countries to report cases before the virus started to spread worldwide. South Korea declared its first case on the 20th of January 2020 [2]. As the number of cases has rapidly soared due to the large outbreak related to religious meetings of the Shincheonji Church of Jesus [3], it became the second-most affected country in the world after China in late February. However, as the Republic of Korea combated the epidemic actively by taking proactive measures to reduce the number of daily new cases, the country handled the spread of COVID-19 impressively as soon as the first case was declared in its territory. As of April 23, it ranked 29th among the countries most affected by the virus, with 10,702 declared cases [4]. In 2015, South Korea was affected by the Middle East Respiratory Syndrome Coronavirus (MERS-CoV). It recorded 186 cases, including 38 fatalities. The 2015 MERS outbreak revealed the weakness of South Korea’s healthcare system to tackle emerging and re-emerging infectious diseases. Since then, the Republic of Korea has made a change in the systems and policies to be capable of tackling the epidemics successfully [5]. As soon as the COVID-19 outbreak was announced in South Korea, a series of policies and interventions to contain the dissemination of the coronavirus disease were adopted, promptly and effectively. Research to develop a test kit was launched in mid-January, right after the Chinese government shared the genetic sequences of the virus [6]. Thus, when cases were rising up due to community transmission, it has already been able to detect and trace infected people and isolate them swiftly. South Korea remarkably controlled and flattened its curve without any national lockdown, even in Daegu and North Gyeongsang Province where most cases occurred [7]. All these reasons put South Korea as an interesting, but also important, country to analyse and discuss in order to have a clearer comprehension of the measures undertaken as there is no harmonized and coordinated measures worldwide. Scrutinizing how each country has responded to COVID-19 and its consequences may broaden our insights into the COVID-19 pandemic. The present case study will, first, identify the evolution of the outbreak in South Korea. Thereafter, non-pharmaceutical intervention measures undertaken, economic, political, and social impacts, and mathematical prediction will be discussed.

2. Methodology We conducted the case study by analysing the early responses of South Korea to the COVID-19 pandemic. It is a real-time analysis of the situation regarding the Covid-19 epidemic in South Korea as it was conducted during the ongoing pandemic. At the initial phase of the pandemic, the sources of data were limited and there were few peer-reviewed scientific researches available. Therefore, we utilized data from governmental websites such as Korea Centres for Disease Control and Prevention and Korea Ministry of Health and Welfare, governmental reports, WHO publications, scientific articles, and conventional media. The study highlights and analyses responses of the South Korean government through the scientific knowledge and resources we had in April 2020. Based on data provided by the Korean government, Korea Centres for Disease Control and Prevention, the United States Centres for Disease Control and Prevention, and the COVID tracking project, we were able to draw various figures by Microsoft Excel. In addition, the schematic diagram was developed to illustrate the non-pharmaceutical intervention measures. As this case study focuses on the first of the COVID-19 pandemic, all the epidemiological data presented are dated between January and April 2020. Int. J. Environ. Res. Public Health 2020, 17, 9571 3 of 18

3. Findings

3.1. Case Presentation

3.1.1. General Description South Korea is an East Asian country with 51 million inhabitants and half of the population is concentrated in the capital Seoul and its metropolitan area. The density of the population is estimated to be around 503 people per square kilometres, while the density of Seoul is approximately 17,000 people per square kilometres. The median age of the population is 42 years and the proportion of people older than 65 years is 15.5%. The life expectancy of the population is around 83 years. The country has a land border with North Korea and is surrounded by the Yellow Sea and the East Sea that are situated between South Korea and China and South Korea and Japan respectively [8]. According to the Organization for Economic Cooperation and Development (OECD), South Korea is a wealthy and developed country with access to high technologies. The country is considered as the 11th largest economy in the world [9]. Regarding the country’s economic system, the Republic of Korea relies mainly on a strategy of exporting goods. The top export partner is China, its neighbouring country [8]. The climate of South Korea is temperate with four distinct seasons. The annual mean temperature ranges from 10 C to 16 C. The coldest month is January, with a mean temperature ranges from 6 C ◦ ◦ − ◦ to 7 ◦C, while the warmest month is August, with a mean temperature range from 23 ◦C to 27 ◦C. The outbreak of the novel coronavirus in South Korea happened in winter, which is a cold and dry season [10]. Concerning the political aspect, South Korea is a democracy with a president, Moon Jae-In since May 2017. Moon Jae-In is from the Democratic Party of Korea, which is known as a centre-left party. The country has a unicameral parliament composed of 300 members elected for four years. Currently, the Democratic Party of Korea, the president’s party, is the most represented in the National Assembly [11].

3.1.2. Healthcare System Overall, South Korea’s health care system is described as being one of the greatest. The government expenditure for the health system was about 7.6% of its GDP in 2017 [12]. According to Bloomberg’s official ranking, South Korea has the fifth most efficient health care system in the world [13]. In addition, South Korea is the fifth-highest country with Intensive Care Unit (ICU) beds per capita and it has 10.6 beds per 100,000 inhabitants [14]. It was reported that it had 12.6 hospital beds per 1000 inhabitants in 2018, ranked second among OECD countries [9]. As the Republic of Korea is a member state of the International Health Regulations (IHR), in 2017, the joint external evaluation mission took place in order to assess its preparedness for a public health emergency. The mission concluded that “the Republic of Korea has highly sophisticated systems and capacities in place to address emerging and re-emerging infectious disease threats and public health emergencies” [15] (p. 1). South Korea achieved universal health coverage for its population in 1989. In 2000, the National Health Insurance (NHI) was introduced as the only insurance of the country with a uniform contribution schedule and benefits coverage for the citizens [16]. However, one of the major issues of the public health system is that “health-care delivery relies heavily on private providers” [16]. As a result of providers’ behaviour seeking profit, there is an increase in demand for new services and technologies that are not included in the NHI benefit package and it is one of the main reasons for the high level of Out-of-Pocket payments [16]. It was also pointed out the public health sector is poor both in terms of quantity and quality. There are insufficient public health facilities and workforce, and a shortage of finance [17]. Moreover, an increase in the cost of healthcare and overuse of medical services have been major problems caused by not only aging and a rise in the number of patients suffering from chronic diseases but also the inefficient healthcare system [18]. Through the COVID-19 outbreak, South Korea has reconfirmed a perennial problem, the lack of health workforce in general. The army doctors and nurses, volunteers, and public health doctors have been dispatched to affected areas to Int. J. Environ. Res. Public Health 2020, 17, 9571 4 of 18 alleviate a shortage of medical personnel. Especially during the large outbreak in Daegu, 750 public health doctors were newly recruited and sent to serve in Daegu [19]. Public health doctors are male doctors who work in remote areas for three years instead of military service under a substitute military service system and they have been playing a significant role in the containment of the outbreak [20]. Meanwhile, South Korea’s government or the National Health Insurance cover all costs that arose from a diagnostic test to hospital admission for its population and foreigners, if it’s related to the coronavirus disease [21].

3.1.3. Epidemiological Situation of the Country Regarding COVID-19 The Republic of Korea declared its first confirmed case of COVID-19—a Chinese visitor who came from Wuhan—on 20 January 2020 [2]. Thereafter, the virus spread very slowly in the country with only a small number of new cases during the first few weeks of the outbreak. In mid-February, South Korea counted 28 cases in its territory, however, as of the 19 February 2020, the epidemic began to accelerate with a higher number of new cases every day. The main health authority for the COVID-19, the Korea Centres for Disease Control and Prevention (KCDC), decided to raise the level of infectious disease alert to “red”, which is the highest level, on 23 February [22]. This action introduced more strengthened public health measures, for example, social distancing, mask-wearing campaigns and mass diagnostic tests to contain the virus and minimize local propagation in advance. However, the country quickly encountered huge unexpected outbreaks in the local areas. On the 29 February 2020, the country reached its peak of new cases in a single day, reporting 909 cases [23]. The dramatic increase in the number of cases was mainly derived from a large outbreak in Daegu, the fourth biggest city with 2.5 million people, and North Gyeongsang Province [24]. It was turned out that this large outbreak was associated with a fringe religious sect called Shincheonji Church of Jesus. The epidemiological investigation revealed that a massive propagation of the virus took place among worshipers during services [24]. However, the rapid increase in new cases had turned downward after the number of new cases peaked at 909 cases. As the number of new cases has rapidly dropped, the curve of confirmed cases has flattened [25]. Figure1 illustrates the trend in new and cumulative numbers of COVID-19 cases and deaths from late January to April [26,27]. As of 30 April 2020, South Korea has reported 10,765 confirmed cases of COVID-19 with 247 deaths which occurred mostly among those over 60 years old (92%). 63.9% of the cases were found in Daegu, and the Shincheonji-related cluster outbreak accounted for 48.7% of total cases across the country [28]. In spite of spikes in the daily new cases from late February to early March, the number of deaths remained stable as seen in Figure1. In addition, the number of new cases has dropped to around 10 per day and as of 30 April it was reported that 9,059 patients have fully recovered that is 84.2% of the total cases [25]. 619,881 diagnostic tests have been conducted across the country (Figure2) until at the end of April [26,27]. However, it appeared that not only the total numbers of tests but also the early implementation matter. The importance of early reactive case detection becomes clear when we compare cumulative numbers of tests in South Korea and the United States as seen in Figure3[ 26,29,30]. Both countries have confirmed the first COVID-19 case on 20 and 21 January respectively [2,29]. While South Korea expanded case detection immediately, the United States increased the number of tests at late February where the number of confirmed cases was soaring exponentially [29]. Figure4 shows sex- and age-disaggregated data on reported COVID-19 cases as of 30 April. The male to female ratio was confirmed approximately 4:6 (M:F) and young adults aged 20–29 was the age group with the highest rate of infection, which is 27.42% of total infections [25]. Int. J. Environ. Res. Public Health 2020, 17, 9571 5 of 18 Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 5 of 17 Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 5 of 17

FigureFigure 1. 1. TheThe trend trend in in the the number number of of confirmed confirmed cases cases of of COVID-19 COVID-19 and and deaths deaths in in South South Korea. Korea. Based Based ononFigure data data 1.from from The Koreatrend Korea inMinistry Ministry the number of of Health Health of confirmed and and Welf Welfare casesare ofand and COVID-19 the the Statistic Statistic and Korea Koreadeaths under underin South the the Korea. Ministry Ministry Based of of StrategyStrategyon data andfrom and Finance Finance Korea [26,27].Ministry [26,27]. of Health and Welfare and the Statistic Korea under the Ministry of Strategy and Finance [26,27].

Figure 2. The trend in the number of confirmed cases of COVID-19 and cumulative tests conducted. BasedFigure on 2. data The fromtrend Korean in the numberMinistry of of confirmed confirmed Health an dcases Welfare of COVID-19 and the Statistic and cumulative Korea under tests the conducted. Ministry ofBased Strategy on data and from Finance Korean [26,27]. Ministry of Health an andd Welfare and the Statistic Korea under the Ministry of Strategy and Finance [[26,27].26,27].

Int. J. J. Environ. Environ. Res. Res. Public Public Health Health 20202020,, 1717,, x 9571 FOR PEER REVIEW 6 of 17 18 Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 6 of 17

Figure 3. Cumulative numbers of test conducted in South Korea compared to the United States since FigureFigurethe first 3. 3. caseCumulativeCumulative was confirmed numbers numbers both of of test testin theirconducted conducted territorie in in Souts. South Datah Korea Korea retrieved compared compared from Koreato to the the United UnitedMinistry States States of Health since since thetheand first firstWelfare, case was wasthe confirmedUSconfirmed Centres both both for in Diseasein their their territories. Controlterritorie ands. Data Data Prevention, retrieved retrieved from and from Koreathe Korea COVID Ministry Ministry tracking of Health of Healthproject and andWelfare,[26,29,30]. Welfare, the US the Centres US Centres for Disease for Disease Control Control and Prevention, and Prevention, and the COVIDand the trackingCOVID projecttracking [26 project,29,30]. [26,29,30].

Figure 4.4. TheThe number number of of confirmed confirmed COVID-19 COVID-19 cases cases by sex by and sex age and groups age groups as of 30 as April. of 30 Data April. retrieved Data Figurefromretrieved Korea 4. fromThe Centres number Korea for Centres of Disease confirmed for Control Disease COVID-19 and Control Prevention cases and Preventionby [25 sex]. and [25]. age groups as of 30 April. Data retrieved from Korea Centres for Disease Control and Prevention [25]. 3.2. Management and Outcome 3.2. Management and Outcome 3.2.1. Non-Pharmaceutical Intervention Measures 3.2.1. Non-Pharmaceutical Intervention Measures 3.2.1. TheNon-Pharmaceutical non-pharmaceutical Intervention interventions Measures (NPIs) are public health measures aiming at decreasing The non-pharmaceutical interventions (NPIs) are public health measures aiming at decreasing transmission by lowering contact rates [31]. As there is no vaccine available against COVID-19, transmissionThe non-pharmaceutical by lowering contact interventions rates [31]. As(NPIs) there are is nopublic vaccine health available measures against aiming COVID-19, at decreasing South South Korea has been implementing proactive and distinctive non-pharmaceutical interventions such transmissionKorea has been by loweringimplementing contact proactive rates [31]. and As distinthere isctive no vaccinenon-pharmaceutical available against interventions COVID-19, such South as as massive case finding and tracing, meticulous managing exposed or confirmed cases, and providing Koreamassive has case been finding implementing and tracing, proactive meticulous and manadistingingctive exposednon-pharmaceutical or confirmed interventions cases, and providing such as massivethe public case a consistentfinding and message tracing, to meticulous wear a mask mana andging its exposedpotential or benefit. confirmed The cases,massive and case providing finding the public a consistent message to wear a mask and its potential benefit. The massive case finding

Int. J. Environ. Res. Public Health 2020, 17, 9571 7 of 18 the public a consistent message to wear a mask and its potential benefit. The massive case finding Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 7 of 17 and tracing could be possible thanks to its ability to produce test kits domestically when community transmissionand tracing has could started be possible [32] and thanks drive-through to its ability screening to produce centres test kits that domestically boosted the when country’s community capacity in testingtransmission [33]. It has was started known [32] that and Southdrive-through Korea prepared screening itselfcentres to that be capable boosted ofthe producing country’s capacity test kits in collaborationin testing [33]. with It thewas privateknown that sector South at the Korea early prepared stage ofitself the to outbreak be capable [32 of]. producing Moreover, test the kits massive in casecollaboration finding and with tracing the private have sector led to at rigorous the early interventionsstage of the outbreak to manage [32]. Moreover, exposed andthe massive confirmed casescase [34 finding]. For instance,and tracing the have government led to rigorous introduced interventions the mobile to manage application exposed to and monitor confirmed self-isolated cases patients[34]. For and instance, the Living the government treatment centresintroduced to isolate the mobile mild application or asymptomatic to monitor patients. self-isolated The patients rapid and innovativeand the responsesLiving treatment of the governmentcentres to isolate were mild believed or asymptomatic to be due to patients. its experience The rapid of MERSand innovative in 2015 [ 32]. Theresponses experience of the of MERSgovernment has left were lessons believed learnt to be and due aff toected its experience the way itof is MERS tackling in 2015 the epidemic[32]. The of experience of MERS has left lessons learnt and affected the way it is tackling the epidemic of COVID- COVID-19. The government was condemned for lack of transparent information to the public, which 19. The government was condemned for lack of transparent information to the public, which significantly contributed to the spread of the disease. It was claimed that many cases would have been significantly contributed to the spread of the disease. It was claimed that many cases would have saved by notifying contacts that they were exposed to the confirmed case and providing information on been saved by notifying contacts that they were exposed to the confirmed case and providing travelinformation history of on confirmed travel history cases of so confirmed that the public cases couldso that avoid the public visiting could affected avoid places. visiting Consequently, affected lawsplaces. passed Consequently, to allow authorities laws passed to trace to allow infected authorities individuals to trace and infected disclose individuals information and on thedisclose cases to theinformation public. Therefore, on the cases when to the the COVID-19 public. Therefore, epidemic when started, the COVID-19 the country epidemic was able started, to set the up country the system for casewas able tracing to set quickly up the [system35]. Although for case tracing it raised quickly the concerns [35]. Although of human it raised rights, the the concerns public of information human disclosedrights, underpinnedthe public information transparent disclosed risk communication underpinned transparent during the risk COVID-19 communication outbreak. during In addition, the SouthCOVID-19 Korea has outbreak. been containing In addition, the South outbreak Korea remarkably has been containing without lockdownsthe outbreak or remarkably border closures without while respectinglockdowns the freedomor border of closures movement while of populationsrespecting the and freedom reducing of themovement economic of impact.populations To illustrate and variousreducing measures the economic and strategies impact. To other illustrate than variou well-knowns measures massive and strategies testing, other we have than well-known developed the schematicmassive diagram testing, (Figurewe have5 )developed and the main the schematic features are diagram further (Figure described 5) and in detailthe main in below. features are further described in detail in below.

FigureFigure 5. The5. The schematic schematic diagram diagram illustrating illustrating interventions interventions SouthSouth KoreaKorea undertook to to tackle tackle COVID- COVID-19. It was19. developedIt was developed to illustrate to illustrate the non-pharmaceutical the non-pharmaceutical interventions interventions of South of KoreaSouth basedKorea on based COVID-19 on PatientCOVID-19 treatment Patient & managementtreatment & management and quarantine and quaran systemtine provided system byprovided Korea by Ministry Korea Ministry of Health of and Health and Welfare [34,36]. Welfare [34,36].

Int. J. Environ. Res. Public Health 2020, 17, 9571 8 of 18

As it is illustrated in Figure5, South Korea took several measures for rigorous case isolations. Confirmed cases were hospitalized in the health facilities or the Living Treatment Centres based on the severity of illness [34]. The Living Treatment Centres, quarantine facilities, were introduced on 2 March 2020, to isolate confirmed cases not requiring hospitalization to minimize the community transmission while reducing the burden on the healthcare system [37]. To monitor patients efficiently in the centres without unnecessary contacts, medical personnel who were assigned to the Living Treatment Centres were using the Self-Quarantine Safety Protection Application through which patients input individual symptoms twice a day. It was also mandatory for those who were under self-quarantine to download this app or the Self-Diagnosis App [38]. Along with the case isolation and treatment, an epidemiologic survey was conducted in each case. The travel history of patients was traced thoroughly using data such as credit card usage, CCTV, and mobile GPS to conduct environmental disinfection and identify contacts [36]. The public information disclosed containing cases’ travel history, in turn, was utilized by companies or individuals to develop the mobile contact tracing apps [39]. The contacts identified had to be self-isolated under monitoring by local governments through the mobile application or phone. During self-quarantine, if a symptom was developed newly, it was directly notified to a public officer through this application. The mobile application was used not only to monitor symptoms but also to spot locations to know whether patients comply with the rule [38]. If those under self-quarantine were found at any place other than their home or a quarantine facility, they would face a fine or imprisonment [36]. The early detection and isolation of cases were underpinned by civil society mobilization, improvement in accessibility and affordability to the screening test and treatment, and prevention of the spread of the outbreak in communities and healthcare facilities. The government has mobilized civil society through risk communication emphasizing the importance of its role and advised people to apply public health measures such as hand washing and wearing a mask and keeping social distance while avoiding large gatherings. Especially, the Ministry of Food and Drug Safety has issued the guideline on the use of masks for the public. It recommended to wear a certified medical mask against COVID-19 from the early phase of the pandemic [40]. Moreover, it has provided the public with transparent information on the outbreak including information regarding confirmed cases through the Regular Briefing of Central Disaster and Safety Countermeasure Headquarters on COVID-19 and press conference, text message alerts, and applications [26,36]. Improvement in accessibility and affordability also played a key role. It was achieved by establishing a great number of screening centres such as drive-through centres [33] and 24 Hours call centres providing consultations and expanding the criteria of the diagnostic test to allow testing asymptomatic people. According to Korea Centres for Disease Control and Prevention, the costs of the treatment and tests of suspected or confirmed cases is covered fully by the National Health Insurance or the government [36]. With a massive case finding and testing, it also monitored the general population by surveillance of pneumonia patients in hospitals and temperature screening at places where people gather such as a train station, a shopping mall, a restaurant, and so on [36]. In order to reduce nosocomial infection of COVID-19, patients with any respiratory symptoms were treated separately in designated hospitals, which can be easily noticeable, so that it can prevent people from exposure to unidentified or confirmed cases. And through the national systems, the International Traveller Information System (ITS) and Drug Utilization Review (DUR), health care facilities were provided with critical information such as patients’ oversea travel history to major countries affected by the outbreak of COVID-19 and whether the patient was a worshiper of Shincheonji Church of Jesus so as to help doctors and nurses to diagnose and take precautions in advance [34,36]. In contrast with the stabilized epidemic in South Korea, European countries and the USA became the epicentres of the pandemic in April where the number of cases and deaths were soaring at terrifying speed [4]. As a result, there was an increase in cases among people arriving from overseas. The Korean government, therefore, decided to conduct the test and put all inbound travellers including Korean Int. J. Environ. Res. Public Health 2020, 17, 9571 9 of 18 citizens arriving from Europe under self-isolation regardless of having symptoms from 1 April [36]. However, there was no travel bans since the emergence of the outbreak except foreigners arriving from Hubei Province, China since 4 February [41]. Also, schools and childcare centres were closed. A new semester was supposed to start on 2 March, but it was postponed a few times due to the persistent possibility of the spread of the disease among students and teachers. As the outbreak and absence of education were prolonged, schools including elementary, middle, and high schools, started opening online schools nationwide since 9 April [42]. Facilities with mass gatherings such as a church, a community child centre, a senior welfare centre were advised to close, however the government has not imposed a national lockdown [36].

3.2.2. Expected or Observed Impact on the Country Economy This unprecedented situation the world is facing, had a significant impact on the national and international economy. China, where the epidemic of COVID-19 has started, plays a key role in travel and commodity markets and supply chains all over the world. Due to its significant role, the noteworthy economic impact of COVID-19 in China has been seen in other countries before it struck them. Also, as the outbreak was spreading, it was causing economic disruption worldwide [9]. The Korea Development Institute (KDI) revealed that in South Korea the production growth did not decrease in January when the few cases were detected [43]. However, the slowdown of exports appeared and domestic demand weakened in February as the COVID-19 outbreak was spread further. The exports have decreased due to not only a decline in demand from China but also disruption of the supply of immediate goods to produce commodities especially automobiles. In addition to deterioration in external factors, domestic demand decreased as a result of a deterioration in economic sentiment [43]. The OECD indicated that annual global GDP growth is expected to decrease by 0.5% in 2020 with negative growth in the first quarter possibly. However, the decline in global growth could be 1.5% relative to 2.9%, the rate expected before the outbreak, if it spreads worldwide resulting in a severe and longer-lasting outbreak. It was also mentioned that the economic adverse impact will be stronger in South Korea, Japan, and Australia which are highly interdependent [9].

3.2.3. Social and Political Disruption The COVID-19 outbreak in South Korea has brought a variety of social impacts across the country. South Korea’s government came under political criticism for not blocking all arrivals from China amid the peak of the epidemic in China. As a result, more than 700,000 people have signed a petition for travel bans from all parts of China and the issue became a big political argument [44]. It has not only caused political debates but also affected the result of the election on 15 April 2020. As this particular situation happened just before the parliament’s election which occurs every four years, the management of the epidemic by President Moon Jae-in and the government has influenced the public vote [45]. Unlike criticism on the government earlier, voters applauded President Moon Jae-in and the government for successful responses to the coronavirus outbreak. As a result, the Democratic Party of Korea had a comfortable majority in the parliamentary elections, thanks in part to the management of the health crisis [45]. As the number of the COVID-19 case increased, South Korea was confronted with a lack of protective equipment, such as masks and hand sanitizers, due to insufficient supply, some domestic merchants’ hoarding and panic buying in the early period of the outbreak. Consequently, people have struggled to secure masks [46]. The government took action to control the supply and distribution of masks and imposed penalties on the hoarding of masks. The government started to manage the whole process of production, logistics, and distribution of masks in South Korea and even banned mask exports. For example, ‘the 5days rotation system’ has been implemented for mask distribution, through which people can buy two masks per week from pharmacies on designated days of week relying on their year of birth [47]. To monitor the purchase of a mask and distribute it equally, the protective mask Int. J. Environ. Res. Public Health 2020, 17, 9571 10 of 18

wasInt. J. newly Environ. included Res. Public inHealth the 2020 Drug, 17,Utilization x FOR PEER REVIEW Review program or DUR, which is a national system 10 of 17 to restrain patients from buying the same drug repeatedly. Consequently, “the 5 days rotation system” could“the be5 days implemented rotation successfullysystem” could by facilitatingbe implement theed pre-existing successfully system, by facili thetating DUR [the48]. pre-existing system,After the the DUR massive [48]. COVID-19 epidemic was found in Daegu and Gyeongbuk areas, a wide range of thoroughAfter the investigations massive COVID-19 were carried epidemic out by was health found authorities in Daegu andand revealedGyeongbuk the connectionareas, a wide between range thisof outbreakthorough andinvestigations the Shincheonji were religiouscarried out movements. by health As authorities a result, all and those revealed churches the were connection forcibly closedbetween by thethis authorities outbreak and temporarily the Shincheonji and even religious one local movements. government As a accused result, all them those of ‘murderchurches due were to wilfulforcibly negligence’. closed by There the authorities was a petition temporarily for the Shincheonji and even church one local to be government dismantled evenaccused if freedom them of of religion‘murder could due beto wilful violated. negligence’. Inversely, There the church’s was a peti worshipperstion for the alleged Shincheonji that they church have to been be dismantled persecuted andeven stigmatized if freedom byof religion society becausecould be someviolated. of them Inversely, were the dismissed church’s and worshippers excluded fromalleged their that works they merelyhave been because persecuted of their and affi liationstigmatized [49]. by society because some of them were dismissed and excluded fromLastly, their inworks spite merely of its remarkable because of results, their affiliation there were [49]. growing human-right concerns on intrusive case tracingLastly, and disclosure in spite of of its private remarkable information results, ofthere cases were [35 ].growing It was oftenhuman-right said that concerns information on intrusive of cases disclosedcase tracing might and be disclosure identifiable. of private In turn, information it could cause of cases a violation [35]. It of was human often rights said that and information stigmatization. of Also,cases as disclosed enormous might and detailed be identifiable. information In turn, was providedit could bycause the government,a violation of people human raised rights concern and onstigmatization. consequent psychological Also, as enormous effects. and The detailed authorities information sent unceasing was provided emergency by the text government, messages, alertingpeople themraised to travelconcern history on consequent of cases and psychological the importance effects. of personal The authorities hygiene andsent social unceasing distance. emergency Therefore, text it messages, alerting them to travel history of cases and the importance of personal hygiene and social might cause various psychological effects such as anxiety, tiredness, and insensitivity due to exceedingly distance. Therefore, it might cause various psychological effects such as anxiety, tiredness, and frequent alerts [35]. insensitivity due to exceedingly frequent alerts [35]. 3.2.4. Mathematical Modelling Predictions 3.2.4. Mathematical Modelling Predictions Mathematical modelling has significant roles in responding to infectious disease outbreaks and establishingMathematical prevention modelling measures. has Itsignificant helps predict roles thein responding size and duration to infectious of the disease outbreak outbreaks or the eff andects ofestablishing public health prevention interventions measures. even It if helps accessible predict information the size and is duration limited. of Choi’s the outbreak work regarding or the effects the of public health interventions even if accessible information is limited. Choi’s work regarding the COVID-19 mathematical modeling was performed right after the Shincheonji outbreak in Daegu, South COVID-19 mathematical modeling was performed right after the Shincheonji outbreak in Daegu, Korea and it projected the virus’ propagation and the results of interventions during the first wave of South Korea and it projected the virus’ propagation and the results of interventions during the first the pandemic [50]. Her work illustrated the reproduction number (R) of the initial outbreak through wave of the pandemic [50]. Her work illustrated the reproduction number (R) of the initial outbreak the SEIHR model and served as mathematical modeling predictions according to its possible scenarios through the SEIHR model and served as mathematical modeling predictions according to its possible the reproduction number (R) refers to how many secondary individuals can be infected by a primary scenarios the reproduction number (R) refers to how many secondary individuals can be infected by individual who is thought to be infected [51]. The estimation of reproduction number (R) is determined a primary individual who is thought to be infected [51]. The estimation of reproduction number (R) by the probability of transmission and the period of infection transmission. The SEIHR compartment is determined by the probability of transmission and the period of infection transmission. The SEIHR consisting of Susceptible (S), Exposed (E), Infectious (I), Hospital-quarantined (H), and Recovered (R), compartment consisting of Susceptible(S), Exposed(E), Infectious(I), Hospital-quarantined(H), and was used. The model is illustrated in Figure6. Recovered(R), was used. The model is illustrated in Figure 6.

FigureFigure 6. 6.Flow Flow diagram diagram of of SEIHR SEIHR model model for for the the COVID-19. COVID-19. Reproduced Reproduced from from [50 [50],], copyright copyright 2020, 2020, the Koreanthe Korean Society Society of Epidemiology. of Epidemiology.

AccordingAccording to to the the study, study, the the estimated estimated reproduction reproduction numbers numbers (R) ranged(R) ranged from from 3.539 to3.539 3.476 to (based3.476 on(based the confirmed on the confirmed case from 29case February from February to 4 March 29th 2020). to Moreover,March 4th, if no2020). virus Moreover, containment if no measures virus werecontainment introduced measures in Daegu were and introduced North Gyeongsang in Daegu and province North Gyeongsang (Gyeongbuk), province the expected (Gyeongbuk), peak point the wouldexpected be 5 peak April point 2020 would and the be infected 5 April number 2020 and of th casese infected would number have reached of cases 22,389 would (Figure have7 ).reached 22,389 (Figure 7). Additionally, the study projects that the epidemic would have ended on June 28th, 2020 and total confirmed cases would have reached 4,992,000 [50]. On the other hand, if there were countermeasures to reduce infections, those would have led to decreasing the transmission rate and the infection transmission period alike, since early detection and case isolations are boosted by the measures. Figure 8 illustrates various curves on the base of the timing of containment and the reduced transmission rates according to given scenarios. (Scenario 1: the day of containment measures becomes effective—5 March, the transmission period—4 days, 90% reduced transmission rate, Scenario 2: the day of containment measures becomes effective—March 5th, the transmission

Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 11 of 17

period—4 days, 99% reduced transmission rate, Scenario 3: the day of containment measures becomes effective—5 March, the transmission period—2 days, 99% reduced transmission rate, Scenario 4: the day of containment measures becomes effective—29 February, the transmission period—4 days, 90% reduced transmission rate, Scenario 5: the day of containment measures Int. J. Environ. Res. Public Health 2020, 17, 9571 11 of 18 becomes effective—29 February, the transmission period—2 days, 75% reduced transmission rate).

Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 11 of 17 period—4 days, 99% reduced transmission rate, Scenario 3: the day of containment measures becomes effective—5 March, the transmission period—2 days, 99% reduced transmission rate, Scenario 4: the day of containment measures becomes effective—29 February, the transmission period—4 days, 90% reduced transmission rate, Scenario 5: the day of containment measures becomes effective—29 February, the transmission period—2 days, 75% reduced transmission rate). FigureFigure 7. 7.Estimated Estimated reproductive reproductive number number by by date date (29 (29 February–4 February–4 March March 2020) 2020) and and their their estimated estimated numbersnumbers of of cases cases if thereif there were were no containmentno containment measure measure in Daegu in Daegu and Northand North Gyeongsang Gyeongsang province province [50]. Reproduced[50]. Reproduced from [50 from], copyright [50], copyright 2020, the 2020, Korean the Korean Society Society of Epidemiology. of Epidemiology.

Additionally, the study projects that the epidemic would have ended on June 28th, 2020 and total confirmed cases would have reached 4,992,000 [50]. On the other hand, if there were countermeasures to reduce infections, those would have led to decreasing the transmission rate and the infection transmission period alike, since early detection and case isolations are boosted by the measures. Figure8 illustrates various curves on the base of the timing of containment and the reduced transmission rates according to given scenarios. (Scenario 1: the day of containment measures becomes effective—5 March, the transmission period—4 days, 90% reduced transmission rate, Scenario 2: the day of containment measures becomes effective—March 5th, the transmission period—4 days, 99% reduced transmission rate, Scenario 3: the day of containment measures becomes effective—5 March, the transmission period—2 days, 99% reduced transmission rate, Scenario 4: the day of containment measures becomes effective—29Figure 7. February,Estimated thereproductive transmission number period—4 by date days,(29 February–4 90% reduced March transmission 2020) and their rate, estimated Scenario 5: the daynumbers of containment of cases if there measures were no becomes containment effective—29 measure February,in Daegu and the North transmission Gyeongsang period—2 province days, 75% reduced[50]. Reproduced transmission from [50], rate). copyright 2020, the Korean Society of Epidemiology.

Figure 8. The predicted number of confirmed cases from February to March if there were proper containment measures according to mathematical modelling in Daegu and North Gyeongsang province [50]. Reproduced from [50], copyright 2020, the Korean Society of Epidemiology.

In another study, behavioural changes with regard to public health measures, such as social distancing, wearing masks, self-isolation and so on, can be factored in the mathematical modelling predictions. Particularly, those infection-prevention measures are crucial in containing the virus when there have not been proper vaccines or therapeutics developed yet. According to Kim’s study, Behavioural-change (SF) and Hospital-quarantine (H) compartments are combined with the SEIR model [52]. The Behavioural-change compartment refers to a group of people who strives to avoid infection by those infection prevention intervention [53]. The model is comprised of Susceptible(S), Exposed(E), Behaviour-changed susceptible (SF), Exposed (E), Infectious (I), Hospital- quarantined(H), and Recovered (R) as illustrated in Figure 9.

FigureFigure 8.8. TheThe predictedpredicted numbernumber ofof confirmedconfirmed casescases fromfrom FebruaryFebruary toto MarchMarch ifif therethere werewere properproper containmentcontainment measuresmeasures accordingaccording toto mathematicalmathematical modellingmodelling inin DaeguDaegu andand NorthNorth GyeongsangGyeongsang provinceprovince [ 50[50].]. ReproducedReproduced fromfrom [50[50],], copyright copyright 2020, 2020, the the Korean Korean Society Society of of Epidemiology. Epidemiology.

InIn anotheranother study,study, behaviouralbehavioural changeschanges withwith regardregard toto publicpublic healthhealth measures,measures, suchsuch asas socialsocial distancing,distancing, wearingwearing masks,masks, self-isolationself-isolation andand soso on,on, cancan bebe factoredfactored inin thethe mathematical mathematical modellingmodelling predictions. Particularly, those infection-prevention measures are crucial in containing the virus when there have not been proper vaccines or therapeutics developed yet. According to Kim’s study, Behavioural-change (SF) and Hospital-quarantine (H) compartments are combined with the SEIR model [52]. The Behavioural-change compartment refers to a group of people who strives to avoid infection by those infection prevention intervention [53]. The model is comprised of Susceptible(S), Exposed(E), Behaviour-changed susceptible (SF), Exposed (E), Infectious (I), Hospital- quarantined(H), and Recovered (R) as illustrated in Figure 9.

Int. J. Environ. Res. Public Health 2020, 17, 9571 12 of 18 predictions. Particularly, those infection-prevention measures are crucial in containing the virus when there have not been proper vaccines or therapeutics developed yet. According to Kim’s study, Behavioural-change (SF) and Hospital-quarantine (H) compartments are combined with the SEIR model [52]. The Behavioural-change compartment refers to a group of people who strives to avoid Int.infection J. Environ. by Res. those Public infection Health 2020 prevention, 17, x FOR PEER intervention REVIEW [53]. The model is comprised of Susceptible(S), 12 of 17 Exposed(E), Behaviour-changed susceptible (SF), Exposed (E), Infectious (I), Hospital-quarantined(H), and Recovered (R) as illustrated in Figure9. Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 12 of 17

Figure 9. Flow diagram of the behavioural change added SEIHR model for the COVID-19 [52].

Reproduced from [52], copyright 2020, the Korean Society of Epidemiology. FigureFigure 9. Flow 9. Flow diagram diagram of of the the behavioural behavioural changechange added added SEIHR SEIHR model model for forthe theCOVID-19 COVID-19 [52]. [52]. TheReproduced Reproducedincreased from fromnumber [52], [52], copyright copyright of cases 2020, 2020, and the the Korean Koreanstrengthen Society Societying of Epidemiology. Epidemiology.of public health measures drives the Susceptible (S) group of people to move to the Behavioural-changed susceptible (SF) group. This The increasedThe increased number number of cases of andcases strengthening and strengthen ofing public of healthpublic measureshealth measures drives thedrives Susceptible the could result in decreasing the probability of transmission in the Behavioural-changed susceptible (SF) Susceptible (S) group of people to move to the Behavioural-changed susceptible (SF) group. This (S) group of people to move to the Behavioural-changed susceptible (SF) group. This could result groupcould. The result study in decreasing also deals the probabilitywith the ofoutbreak transmission of Daeguin the Behavioural-changed and North Gyeongsang susceptible province (SF) in decreasing the probability of transmission in the Behavioural-changed susceptible (SF) group. (Gyeongbuk)group. The where study there also wasdeals a dramaticwith the outbreaksurge in ofthe Daegu number and of North cases Gyeongsangat the same provinceperiod. The The study also deals with the outbreak of Daegu and North Gyeongsang province (Gyeongbuk) where mathematical(Gyeongbuk) modelling where there predicts was athat dramatic approximately surge in the 13,800 number cases of caseswould at theoccur same across period. the The whole there was a dramatic surge in the number of cases at the same period. The mathematical modelling countrymathematical and the last modelling case would predicts be thatconfirmed approximately on June 13,800 14th, cases 2020. would Particularly occur across in the the Daegu whole and predicts that approximately 13,800 cases would occur across the whole country and the last case would Gyeongbukcountry regions,and the lastthe casecases would were beexpected confirmed to onreach June approximately 14th, 2020. Particularly 11,400 and in the would Daegu end and on 27 be confirmed on June 14th, 2020. Particularly in the Daegu and Gyeongbuk regions, the cases were May 2020Gyeongbuk (Figure regions, 10) [52]. the cases were expected to reach approximately 11,400 and would end on 27 expectedMay to2020 reach (Figure approximately 10) [52]. 11,400 and would end on 27 May 2020 (Figure 10)[52].

Figure 10. (A) Predicted cumulative confirmed cases over time, (B) Predicted isolated cases over time Figure 10. (A) Predicted cumulative confirmed cases over time, (B) Predicted isolated cases over Figure[52]. 10. Reproduced (A) Predicted from cumulative [52], copyright confirmed 2020, the cases Korean over Society time, of (B Epidemiology.) Predicted isolated cases over time time [52]. Reproduced from [52], copyright 2020, the Korean Society of Epidemiology. [52]. Reproduced from [52], copyright 2020, the Korean Society of Epidemiology. Both mathematical modelling predictions illustrate different results and patterns in association Both mathematical modelling predictions illustrate different results and patterns in association Bothwith pre-conditionsmathematical and modelling dynamics. predictions Even though illustra the governmentte different raised results the highestand patterns level of ininfectious association with pre-conditions and dynamics. Even though the government raised the highest level of infectious with pre-conditionsdisease alert in the and country dynamics. and strict Even intervention though the po governmentlicies have been raised implemented, the highest it islevel necessary of infectious to diseasefind alert out in whether the country those and measures strict intervention have been policies effective have and been maintainable implemented, as time it is necessaryhas passed. to find disease alert in the country and strict intervention policies have been implemented, it is necessary to out whetherMathematical those modelling measures is have used beenas a useful effective tool andin the maintainable decision making as timeprocess has in passed.public health. Mathematical Both find out whether those measures have been effective and maintainable as time has passed. modellingmathematical is used asmodelling a useful predictions tool in the decisioncommonly making indicates process the outbreaks in public health.in South Both Korea mathematical would Mathematical modelling is used as a useful tool in the decision making process in public health. Both modellingcontinue predictions at least until commonly May, so the indicates public health the outbreaks measures in should South be Korea maintained. would continue at least until mathematical modelling predictions commonly indicates the outbreaks in South Korea would May, so the public health measures should be maintained. continue4. Discussion at least until May, so the public health measures should be maintained. The WHO’s announcement of the coronavirus outbreak as the “pandemic” on 11 March 2020, 4. Discussionfollowed the rapid spread of the virus around the world [54]. People were perplexed by the Theunprecedented WHO’s announcement propagation of of a newthe coronavirusviral disease andoutbreak its huge as impacts the “pandemic” on public health on 11 as March well as 2020, followedon multiple the rapid aspects spread of the of globalthe virus community. around Ho thewever, world each [54]. country People has werebeen facingperplexed different by the circumstances as the responses to COVID-19 are immensely different among countries [55]. The unprecedented propagation of a new viral disease and its huge impacts on public health as well as findings in this case study, have shown how South Korea has responded to the COVID-19 with social, on multiple aspects of the global community. However, each country has been facing different circumstances as the responses to COVID-19 are immensely different among countries [55]. The findings in this case study, have shown how South Korea has responded to the COVID-19 with social,

Int. J. Environ. Res. Public Health 2020, 17, 9571 13 of 18

4. Discussion The WHO’s announcement of the coronavirus outbreak as the “pandemic” on 11 March 2020, followed the rapid spread of the virus around the world [54]. People were perplexed by the unprecedented propagation of a new viral disease and its huge impacts on public health as well as on multiple aspects of the global community. However, each country has been facing different circumstances as the responses to COVID-19 are immensely different among countries [55]. The findings in this case study, have shown how South Korea has responded to the COVID-19 with social, economic, political, and epidemiological impacts and it appeared to have impressive measures and results. As many other countries have been being criticized for poor outcomes regarding COVID-19, the Korean government had faced condemnation of the management of the MERS outbreak in 2015 that caused 186 cases and 38 deaths. Such experiences helped the government to establish improved strategies and measures against COVID-19. Consequently, it showed relatively better preparedness and outcomes than the rest of the world. South Korea encountered the epidemic earlier than other countries because of its geographic adjacency and international relationship with China. The first case was reported on 20 January 2020 and it did not take long to encounter community transmission which led to the peak of confirmed daily cases at 909 on 29 February. The new cases were mainly concentrated in Daegu and its surrounding Province, North Gyeongsang Province. The subsequent epidemiological investigation uncovered this large outbreak was associated with meetings of a fringe religious sect called Shincheonji. The Sincheonji-related outbreak accounted for nearly half (48.7%) of the total cases. As a result, South Korea was one of the most-affected countries with a high number of cases and deaths during the initial phase of the pandemic. However, South Korea has successfully flattened the curve of new cases after reaching the peak and the downward trend was maintained continuously. As of 30 April, the number of new cases per day were 4 and 84.2% of the confirmed cases were fully recovered. The number of confirmed cases and deaths were 10,765 and 247 respectively. The Korean government has developed the plan and strategy to confront the outbreak of the new virus prior to its arrival. The government took the drastic and proactive intervention strategies including performing early and massive coronavirus tests, tracing contracts, and isolating cases instead of blocking the door completely against affected countries or putting the affected areas or whole population on lockdown. These strategies could be possible thanks to remarkable actions and innovation. For instance, since the government started the development of diagnostic test kits in collaboration with the private sector before having confirmed the first case in the country, it was able to produce test kits domestically at the early stage of the epidemic. Moreover, innovative ideas such as ‘drive-thru’ screening centres, the mobile Self-quarantine Safety Protection Application, the Living Treatment Centres were introduced. The drive thru screening centres gave an easy and safe way for both medical personnel and the public, thereby diagnostic tests could be conducted rapidly on a large scale. As of 30 April, the number of COVID-19 tests performed was 619,881. More importantly, Figure3 shows the importance of early reactive case detection by comparison with the trend in tests conducted in the United States which reported the first COVID-19 case the day after South Korea confirmed its first. As there has not been a single effective measure nor vaccine, the role of the public is also significantly important. Such importance of individual behaviours was taken into account the mathematical modelling. It cleared showed it significance in conjunction with tightened public health measures. Likewise, the Korean government emphasized the importance of the role of individual citizens and urged the public to abide by public health advices through effective risk communication. The government has provided the pubic with transparent information on the pandemic and the consistent message regarding wearing a mask and its effectiveness even when the World Health Organization stated that there was no sufficient evidence of effectiveness of masks and concluded not to recommend the use of masks against COVID-19 for the general population [56]. Moreover, the government actively intervened in the market to distribute enough masks to the people when there was a shortage of masks all over the country. Besides, South Korea improved affordability and Int. J. Environ. Res. Public Health 2020, 17, 9571 14 of 18 accessibility of tests and treatment and undertook measures to prevent further community transmission such as continuous monitoring of the public and hospitals and designating hospitals where patients with a respiratory symptom were treated separately from the others (Figure5). However, South Korea has confronted the problems of the healthcare system during the pandemic. It has the poor public health sector, heavily relying on private providers and there is insufficient health workforce in general. Therefore, the government has mobilized army doctors and nurses, voluntary medical personnel, and public health doctors to mitigate the shortage of medical personnel. Especially, the public health doctors who work in a remote area instead of military service, played a significant role when the large outbreak occurred in Daegu and North Gyeongbuk Province. The COVID-19 pandemic and measures have brought enormous impacts on the country. Given its economic partnership with China, the economic disruption was already observed before it spread nationwide in South Korea due to the slowdown of exports and weakened domestic demand. It also caused social conflicts and political debates especially when the Shincheonji-related large outbreak occurred. However, as the government has flattened the curve of numbers of new cases rapidly, it has regained the trust of the people which affected the result of the general election in April 2020.

5. Conclusions Although several characteristics of the virus were revealed in the early epidemic case studies in China, the information of the virus was not fully discovered or not open clearly to the global society at the initial phase of the COVID-19 pandemic. Therefore, responses of each country to COVID-19 were highly divergent due to lack of coordinated guidelines worldwide and it has resulted in different outcomes among countries. South Korea is one of the countries that have shown better outcomes in terms of COVID-19 than the rest of the world. The interventions and strategies undertaken by South Korea appeared to be effective. The most distinctive feature is the drastic and proactive strategy. Instead of implementing traditional measures of containment of infectious diseases, the Korean government put emphasis on proactive case finding, contact tracing, and rapid isolation of cases. Moreover, it was underpinned by remarkable measures such as risk communication, civil society mobilization, and innovation. The second feature is that the Korean government did not implement travel restrictions except for arrivals from Wuhan, China, respecting the IHR of WHO while the rest of the world closed their borders rapidly [57]. Given the situations of the outbreak in the countries where travel bans or border closures were applied promptly, the question on the effectiveness of travel restrictions is still raised. The key findings highlight the importance of the proactive strategy and the responses of South Korea to COVID-19 provide broadened insights. However, a further research is needed in order to understand the association between each measure and the outcome and the extent of its effectiveness before applying them in other countries. Therefore, it is also important to develop methods to measure and quantify the effectiveness of these responses. As the pandemic is still ongoing, there is a compelling need to accumulate the scientific evidence and evaluate the full extent of performances of South Korea on the COVID-19 pandemic and social, economic, and political impacts after the pandemic.

Author Contributions: E.J., M.H., and H.J. conducted literature review. E.J., M.H., and H.J. wrote the paper. E.J., M.H., and H.J. reviewed and edited several versions of the manuscript. E.J. developed figures. M.K. provided feedback. A.F. supervised. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Acknowledgments: We would like to express our special thanks to Sunhwa choi (Department of Cancer Control and Population Health at the National Cancer Center, Korea), Soyoung Kim and Eunok Jung (Department of Mathematics at Konkuk university, Korea) for providing us with figures and information on mathematical modelling. We also thank Antoine Flahault, Director of the Institute of Global Health at the University of Geneva, and Liudmila Rozanova for providing their expert knowledge and continuous supervision throughout the writing process. Conflicts of Interest: The authors declare no conflict of interest. Int. J. Environ. Res. Public Health 2020, 17, 9571 15 of 18

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